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McGill Family Medicine Studies Online, 13: e16

Page history last edited by reem.elsherif@mail.mcgill.ca 4 years, 6 months ago

Peretti, Matteo (2018).  Barriers and facilitators associated with antipsychotic deprescribing for individuals with Dementia residing in long-term care as reported by physicians: a mixed methods study. McGill Family Medicine Studies Online, 13: e16

 

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Abstract

Background: Off-label antipsychotic (AP) prescribing for the management of the neuropsychiatric symptoms of dementia in long-term (LTC) care is prevalent despite clinical guidelines and decades of evidence cautioning against this practice.

 

Objectives: The objectives of this study were: (1) To quantify the degree of difficulty physicians experience when attempting to resist AP initiation requests and taper/withdraw APs for LTC residents (2) To identify and quantify physician barriers and facilitators associated with AP deprescribing for LTC residents with dementia in Canada; and (3) To obtain an in-depth and rich understanding of how these barriers and facilitators unfold in clinical practice.

 

Methods: A two-phase, explanatory sequential mixed methods design was used. First, a cross-sectional quantitative survey identified potential barriers and facilitators associated with both resisting AP initiation requests and tapering or discontinuing existing AP prescriptions. Multivariable logistic regression models were used to identify survey items associated with the main outcomes. Important barriers and facilitators were then explored in semi-structured interviews with survey respondents. Interview transcripts were coded using thematic analysis.

 

Results: Multivariable analyses revealed that difficulty resisting AP initiation requests was associated with pressure from nursing staff (RR = 2.35; 95% CI, 1.01 - 5.51), reluctance to question a colleagues' decision to prescribe APs (RR = 2.45; 95% CI, 1.16 - 5.16), lack of access to mental health specialist consultants (RR = 2.51; 95% CI, 1.25 - 5.03), and was more common among physicians who identify as female (RR = 3.67; 95% CI, 1.44 - 9.39). No variables were significantly associated with difficulty deprescribing APs. The thematic analysis highlighted the importance of communicating with families, and how limited LTC resources serve to reinforce the maintenance of AP prescriptions due to concern regarding symptom re-emergence.

 

Conclusions: Our survey results contribute to the LTC AP deprescribing literature by adding the much-needed physician perspective with regard to specific barriers and facilitators. The follow-up interviews provide a nuanced understanding of complex interplay between physicians and the LTC milieu, and how these forces can both inhibit and assist physicians' deprescribing efforts. Future interventions would benefit from adopting a multifaceted approach that accounts for each facility's context and the perspectives of its various stakeholders. 

 

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